"One cannot refuse to eat just because
there is a chance of being choked."
-- Chinese proverb

This chapter presents complications that may occur with all forms of surgery on or around the eyelids. When a procedure carries known procedure-specific side-effects (such as complications, for instance, associated with eyebrow lift or Botox), those risks will be noted in the particular chapter detailing that operation.

Despite the comprehensive list that appears below, blepharoplasty is a relatively safe and effective operation when compared to many more widely invasive plastic and reconstructive surgical operations. The vast majority of patients who undergo cosmetic eyelid surgery are pleased with their results.

Slideshow: Complications After Eyelid Surgery

• Infection: Infection is a risk with any and all surgery, including surgery on or around the eyelids. Because of the eyelid's good blood circulation, however, elective surgery performed under sterile conditions seldom results in serious infection.

• Bleeding: Continued bleeding after blepharoplasty may require reopening of the eyelid wound and either cauterization of the bleeding vessel and/or evacuation of the clot ("hematoma"). The most common sites of bleeding are the fat pockets and the orbicularis muscle.

• Wound separation: The edges of the eyelid skin closure may separate, especially in the first day or two after suture removal. A small separation may close spontaneously or with the help of supporting tape. A larger separation may require suturing. Generally, treated wound separations have minimal permanent effect on the final result.

• Suture cysts: Tiny white cysts (milia) may develop in the suture line. While most disappear without treatment, removal of a resistant cyst is simple and quick.

• Asymmetry: Eyelids that look good individually may not match as a pair, and such asymmetry introduced by surgery may be cosmetically disturbing. Asymmetries can involve the height and shape of the upper eyelid crease, excursion of the lower eyelid margin, residual skin or fat, and so on. If noticeable asymmetry persists past a reasonable waiting period of time (usually three to six months), your surgeon may suggest re-operation.

• Insufficient skin removal: While blepharoplasty undercorrection is always preferable to overcorrection, an objectionable amount of undercorrection may call for a "touch-up" operation. Be aware that what sometimes appears to be an undercorrection may, in fact, represent a basic and inherent limitation of blepharoplasty surgery in that particular patient. For instance, mild hooding of upper eyelid skin on the side closest the temple may be secondary to a mild downward droop of a patient's eyebrow. Likewise, skin excess in the medial canthus towards the nose may be more related more to a patient's forehead droop than an underaggressive blepharoplasty. Remember two things: (1) blepharoplasty is an operation on the eyelids alone and can accomplish only so much for the face, and (2) attempting to leave eyelid skin "bone tight" in either the upper or lower eyelids is courting disaster.

• Excessive skin removal: Excessive removal of upper eyelid skin may interfere with proper closure of the eyelids ("lagophthalmos") during blinking or especially when sleeping. Extreme shortage may distort the eyelid margin and create a widening of the palpebral fissure (opening between the eyelids) that is both cosmetically and functionally objectionable ("eyelid retraction"). Excessive removal of lower eyelid skin may cause the eyelid margin to pull away from the eye surface ("ectropion"). When mild, the main symptom may be overflow tearing due to the pulling away of the tear drain opening from the surface of the eye ("punctal eversion"). If more severe, the entire lid may be pulled downward. Problems resulting from skin overcorrection are annoying at best and dangerous at worst; almost all such complications require surgical intervention.

• Insufficient fat removal: When insufficient fat removal creates a noticeable or asymmetric blemish, further removal may be indicated.

• Excessive fat removal: Fat removal from the upper eyelid may create a lid crease that appears too high and deep ("superior sulcus defect"). Fat removal in the lower eyelids may create a hollowed-out appearance ("inferior sulcus defect"). Hollowness may develop either immediately or years after surgery.

• Excessive muscle removal: Aggressive removal of orbicularis muscle from the upper eyelid may hollow the superior sulcus and in the lower eyelid may lead to weakened eyelid closure and support.

• Excessive internal scarring: Internal scarring ("fibrosis") or shrinkage of the internal eyelid layers below the skin may cause distortion, limitation of movement, and retraction. Massage may help in mild cases, but surgery may be needed to improve appearance and function.

• Excessive external scarring: Visible scarring on the skin may be aggravated by poor healing in damaged or sensitive skin, suboptimal placement of incisions (too high in the upper eyelid; too low in the lower eyelid), delayed suture removal, prolonged fragility with laser incisions, failure to follow postoperative instructions, and other factors.

• Inappropriate crease: An upper crease placed too high tends to "feminize" the male eyelid. An overly high or arched upper crease in an Asian eyelid may "round the eye" and make it appear inconsistent with the rest of the face. Excessive upper skin removal and/or failure to fixate the crease during suture closure may allow the final scar to migrate higher and be visible.

• Rounding at the lateral commissure: Rounding of the acute angle where the outer upper and eyelids come together may be caused by excess skin and/or muscle resection or a result of canthoplasty - canthopexy. If subtle, the deformity is best ignored; if more noticeable, surgical revision may be undertaken.

• Drooping upper eyelid: Blepharoplasty may "unveil" a pre-existing but unrecognized drooping upper eyelid (that is, not a baggy lid but one that rides too low), a condition known as "ptosis". Less commonly, injury to the levator muscle and tendon (aponeurosis) may cause ptosis to appear in a previously healthy levator system. Mild ptosis after blepharoplasty is not rare and may persist for several weeks to months. If the condition does not resolve with time, exploratory surgery may be indicated.

• Fat necrosis: Due to surgical manipulation, pea-sized ares of fat may die over the first few weeks, turn hard or rubbery, and become tender to touch. Massage may hasten resolution but only if healing if far enough along and the manuever has been approved by your surgeon.

• Swelling on the eyeball surface: Collection of post-surgical inflammatory fluid (edema) or temporary disruption of lymphatic drainage (chemosis) may cause swelling on the eye surface that is uncomfortable and cosmetically frustrating. It is not rare and has been reported in over 10% of patients undergoing skin-incision lower blepharoplasty. Nearly all cases resolve within three weeks to three months. Chronic chemosis persisting six months or more may occur rarely and is of unknown cause. Lubrication, medicated eye drops, patching, and passing time are generally curative.

• Injury to the lacrimal system: If the main tear-producing gland is injured, prolonged swelling in the outer portion of upper eyelid may persist for several weeks. No additional surgery is required. Injury to the drainage canal ("canalicular laceration") is rare but requires immediate repair by an ophthalmologist.

• Double vision: If the muscles that move the eyeball are injured or scarring occurs in the fat surrounding the eye muscles, temporary or permanent double vision may result. The most vulnerable muscles are the superior and inferior oblique muscles and the inferior rectus muscle, all of which course within or near the fat of the eyelids. Attempt at correction of any resulting double vision ("diplopia") may require the services of an ophthalmologist specializing in eye muscle surgery ("strabismus surgery specialist")

• Loss of vision: Very mild reduction of vision following blepharoplasty is not uncommon and is usually due to swelling, excessive tearing and mucus production, and/or secondary to ointments or drops used after surgery. Catastrophic loss of vision (that is, permanent blindness) occurs rarely (less than 1 in 10,000 cases) and is most often associated with brisk bleeding that makes its way to the area in back of the eyeball ("orbital or retrobulbar hemorrhage") and generates enough pressure inside of the socket to cut off the normal blood flow to the retina (although the exact mechanism is not fully understood). Other possible causes of vision loss include damage to the optic nerve, needle penetration of the eyeball, and advanced eye or orbital infection. Most deep orbital hemorrhage occurs within 48 hours of surgery and is not at all subtle, usually associated with intense pain, double vision, and a sudden bulging forward of the eye. Such symptoms indicate an extreme emergency and should be reported to the surgeon immediately. In most cases, emergency surgery by an ophthalmologist is necessary.

• Complications of anesthesia: While hardly unique to cosmetic eyelid surgery, complications may occur from the anesthesia alone, including severe allergic reactions, blood pressure fluctuations, and serious heart and breathing difficulties. Such problems are more common with the administration of intravenous and/or inhaled anesthetic agents than with local anesthesia using oral sedation.

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